Multiple Sclerosis (MS)
Overview
Multiple Sclerosis (MS) is a
chronic progressive, non
contagious, degenerative
disease of the CNS
characterized by
demyelinization of neurons.
The Human Nervous System
Areas affected by MS
Brain
Spinal cord
Optic nerves
Pathologic triad
CNS inflammation
Demyelination
Gliosis (scarring)
History of Multiple Sclerosis
The earliest description of MS was recorded in
Holland on August 4, 142. But the history of the
disease really begins in the 19th century with the first
clear illustrations and clinical description of the
disease beginning to appear in 1838.
The first actual case was diagnosed in 1849. It was
Dr. Jean-Martin Charcot who is credited for giving
the first signs and symptoms of Multiple Sclerosis.
Multiple Sclerosis -
Epidemiology
Worldwide occurrence:1.1 – 2.5 million cases
Female: male ratio = 2:1
In Canada an estimated that 55,000-75,000
people have multiple sclerosis
Affects nearly 500,000 individuals in the US
Occurs most frequently between ages 25 - 35
Genetic and the Immune
System
XX
2
XX Immune
XX Response
XX XX 10
3
Genes
9 1 XX
XX 6
X
XX XX
13 7
11
XX XX
12 XX XX 5
4
8
Factors Contributing for MS
Genetic Factors
Gender: Women are 2 to 3 times more likely to get the
disease.
Family history of MS: A family history increases the
risk
Race: MS appears more in Caucasians than in other
groups
Environmental factors
Latitude: As you increase latitude, mainly above and
below 40° latitude. MS is more common. It is five times
more likely in temperate and cooler climate regions.
World Distribution of MS
Factors Contributing for MS
Environmental factors
Socioeconomic status: Least common in rural and
lower class.
Migration: The age at which you may move may also
be an important factor. “If you move before the age of
15, your risk is likely to that of the people in the country
you move to. If you move after the age of 15, your risk
stays fixed at that of the country
you grew up in”.
Factors Contributing for MS
Environmental factors
Infection:
“They believe MS is a delayed reaction to a viral
infection contracted during childhood by a genetically
susceptible person” (O’Connor 13). The viral infections
may include shingles, chicken pox, measles, or certain
herpes. An idea they also have concerns the age at
which you get the infection. The older you are the
higher the risk for MS.
***Remember that in warm countries, children contract viruses at a younger
age.
Not Everyone with a Genetic Risk
Will Develop MS – Why?
Risk is modified by Environmental
factors
Sunlight
Diet (e.g., vitamin D)
Other lifetime experiences
(infections?)
Multiple Sclerosis - Causes
The exact cause of multiple sclerosis is not
clear
MS patients, have a higher number of
immune cells which suggests there might be
an immune response; this is suspected to be
due to a virus or genetic defect
Other causes are environmental and
hereditary
How Does it work?
Demyelination of Nerve Fibers
in MS
Positive conduction
abnormalities
generations of spontaneous
ectopic impulses and abnormal
“crosstalk” between demyelinated
axons
Negative conduction
abnormalities The destruction of the
slowed axonal conduction, myelin sheath leads to
variable conduction blocks occur impaired communication
in the presence of high- but not between nerve cells
-low frequency volleys of
impulse.
Mode of Action
The immune system attacks axons, causing
destruction of the myelin sheath resulting in a
Conduction Block which leads to permanent loss
of function.
MS is an Immune-Mediated Disease
BBB=blood-brain barrier; APC=antigen-presenting cell.
Adapted from Miller et al. Continuum: Multiple Sclerosis (Part A). 1999;5:7.
Pathophysiology
Autoimmune response results in damage and loss of fibers.
Nerves can regain myelin, but the process is not fast enough to
avoid the deterioration that occurs
Astrocytes form scars where myelin formerly existed
Inflammation, loss of myelin of nerve fibers, and the scarring
that follows result in reduced transmission of nerve signals
within the CNS.
Type of symptoms and severity vary widely due to the location
of the scar tissue and the extent of demyelination
Click Pathophysiology of MS
Multiple Sclerosis Signs and
Symptoms
Vision impairment Memory loss
Lhermitte‘s sign- Depression
momentary Urinary and bowel
paresthesia problems
Difficulty in walking + Babinski’s reflex
Weakness and
exhaustion
Nursing Diagnosis
Nursing Diagnosis
1. Pain chronic r/t stimulations of free nerve
ending 2 to destructions of myelinated axons.
2. Impaired sensory perception r/t nonsynaptic
transmission of demyelinated axons.
3. Fatigue r/t decrease energy production
4. Paralysis r/t conduction block of demyelinated
axons.
Cont.. Nursing Diagnosis
5. Low self Esteem r/t change in brain
structure/function.
6. Ineffective coping r/t multiple life changes.
7. Risk for care givers role train r/t severity of the
care receiver, duration of care giving required
8. Deficient knowledge regarding condition,
prognosis, complications, treatment and need
r/t unfamiliarity of information resources.
Multiple Sclerosis - Types
There are 4 major types of MS
Relapsing-remitting MS (RR-MS)
Primary-progressive MS (PP-MS)
Progressive-relapsing MS (PR-MS)
Secondary-progressive MS (SP-MS)
Multiple Sclerosis - Types
Relapsing-remitting MS (RR-MS)
More than 80%
Defined clinical exacerbation of
neurological symptoms
Followed by complete or incomplete
remission during which the person fully
or partially recovers from the deficits
acquired during relapse
Multiple Sclerosis - Types
Primary-progressive MS (PP-MS)
10 to 20%
Gradual progression of the disease
No overlapping relapses and remissions
Multiple Sclerosis - Types
Progressive-relapsing MS (PR-MS)
Rare
Initially presenting as PP-MS, however during
the course of the disease the individuals
develop true neurologic exacerbations
Steady progression of clinical neurological
damage with superimposed relapses and
remissions.
Multiple Sclerosis - Types
Secondary Progressive MS (SP-MS)
SP-MS is characterized by a steady progression
of neurological damage with or without
superimposed relapses and minor remissions
Individuals with SP-MS will have experienced a
period of RR-MS, which may have lasted from
2 to 40 years
Any super-imposed relapses and remissions
fade over time
How Is MS Diagnosed?
At least two episodes of symptoms
Occur at different point in time
Result from involvement of different areas
of the central nervous system
Absence of other treatable causes for
the symptoms
Results of neurological testing
DIAGNOSTIC WORKUP
Radiologic studies
It is diagnosed by neurological
examination and brain MRI scans
Signs of two separate attacks with
demyelination of CNS supports the
diagnosis.
Magnetic Resonance
Imaging (MRI)
Is a noninvasive diagnostic
scanning technique in which the
client is placed in a magnetic field.
MRI provides a better contrast
between normal and abnormal
tissue than the CT scan. For
visualization of the brain, spine,
limbs, and joints, heart, blood
vessels, abdomen and pelvis.
Brain Atrophy (Shrinkage)
in Untreated MS
Images acquired over the course of 7 years from a single person
with untreated MS Brain atrophy is seen as the enlargement of
the ventricle and sulcal spaces. In untreated MS, by year 2, up to
6% of brain volume can be lost.2
Assessment of the Appearance of
MS Lesions Over time
Time lapse = 1 year
Serum and CSF Analysis
Blood tests
Lumbar Puncture (spinal tap)
- If MS is present, persistent elevated
of CSF protein IgG (oligoclonal
antibody) bands can be seen in spinal
fluid which is an additional confirmatory
test.
Symptom Management –
Examples
Pain control
Management of impaired bladder and
bowel function
Anti-spasmodic drugs
Treatment of fatigue
Splinting for contractures
Counseling
The end..
References
All About MS @ http://www.mult-sclerosis.org/
Multiple Sclerosis Society @ http://www.mssociety.org.uk/
The National Multiple Sclerosis Society @ http://www.nationalmssociety.org/
All About MS @ http://www.mult-sclerosis.org/
Multiple Sclerosis Society @ http://www.mssociety.org.uk/
The National Multiple Sclerosis Society @ http://www.nationalmssociety.org
Resource Link for the MS Foundation (MS Facts) @ http://www.msfacts.org/
Barnes, David. Multiple Sclerosis Questions and Answers, Merit Publishing International, Florida, 2000
O’Connor, Dr. Paul. Multiple Sclerosis The Facts You Need, Firefly Books Inc., New York, 1999.
Christopher Bourque, Diagnostic Issues
Ref :“DEMYELINATING DISEASE MULTIPLE SCLEROSIS”ELLEN MARDER MD PHD, 8/4/2005
Multiple Sclerosis: Hope Through Research, 06 April
2003http://intelihealth.com/IH/ihtIH/WSIHW000/8320/21151/195415.html?d=dmtcontent>,
www.jama.com on February 14, 2009
